[Body composition in chronic obstructive lung patients. Comparison of bioelectric impedance and anthropometry]. / Composition corporelle des patients ayant une bronchopneumopathie chronique obstructive. Comparaison de l'impédancemétrie bioélectrique et de l'anthropométrie.

Malnutrition is associated with poor prognosis in patients with chronic obstructive pulmonary disease (COPD). Body weight is not a reliable evaluation criterium. Body composition which is more useful can be determined routinely using 2 techniques: skinfold thickness anthropometry (Ant) and bioelectrical impedance analysis (BIA). The validity of this last technique has not been demonstrated in patients with COPD. Fat-free mass (FFM) in 58 patients (51 men, 7 women) with stable COPD (FEV1 < 50% of predicted value) was assessed using the 4-skinfold-thickness method (Ant) and BIA (Imp). Statistical analysis included correlation analysis, intraclass correlation coefficient, and the Bland and Altman analysis. Imp-FFM and Ant-FFM correlated well (r = 0.920; p < 0.0001). Intraclass correlation coefficient was high (rI = 0.9065). However, the values were scattered and there was a systematic bias (significant linear regression between the difference in estimates obtained by the 2 methods and the means). As anthropometric measurements are not reliable in the elderly patients, our results suggest that BIA could be a useful tool to determine FFM in patients with COPD. Its validity still has to be tested against a reference method.

[Methods of nutritional assessment in chronic obstructive lung diseases]. / Méthodes d'évaluation nutritionnelle dans la bronchopneumopathie chronique obstructive.

A poor nutritional state is often encountered in the course of chronic obstructive lung disease (COLD) and worsens the prognosis. The methods used to assess nutritional status proposed in the literature vary greatly. We detail here the methods used in clinical practice and in research, describing results obtained in patients with COLD. Appropriate routine tests are discussed. Body weight should be followed in this population, but weight loss may be masked by sodium-water retention. Bioelectric impedancemetry or biphotonic absorptiometry are used to define body composition in patients with COLD. Lean mass can be measured with the creatinine/height index but is difficult in the ambulatory patient. Plasma levels of visceral proteins are often normal and do not appear to be useful markers in these patients. Immunology tests (delayed hypersensitivity, total lymphocyte counts) are not sensitive screening tests. An evaluation of skeletal muscle function using the walking test or an exercise test is recommended before starting a renutrition program and to evaluate its efficacy.

Role of the thermic effect of food in malnutrition of patients with chronic obstructive pulmonary disease.

Malnutrition in patients with chronic obstructive pulmonary disease (COPD) is classically ascribed to an increased resting energy expenditure (REE) secondary to high cost of breathing. However, malnutrition correlates only weakly with the severity of respiratory dysfunction, which suggests other mechanisms. The aim of the present study was to determine the possible role of diet-induced thermogenesis (DIT). Therefore, we evaluated the relationship between DIT and nutritional status, in particular fat-free mass (FFM) estimated by bioelectrical impedance analysis in 26 patients with stable COPD (mean FEV1 +/- SEM = 36.5 +/- 3.8% of predicted). Ten patients were undernourished (weight < 90% of ideal body weight [IBW] and/or FFM < 69% of IBW), and 16 were normally nourished. Diet-induced thermogenesis was determined by comparing postprandial energy expenditure and REE, the latter being measured after an overnight fast and the former over 4 h after a mixed test meal of 0.4 times REE load. No statistical difference in DIT was found between undernourished and eutrophic patients. There was no relationship between DIT and nutritional or functional parameters, notably FFM. These results suggest that malnutrition is not a consequence of an increased DIT.

[Forced expiration. Various current concepts, 50 years after Robert Tiffeneau]. / Expiration forcée. Quelques concepts actuels, 50 ans après Robert Tiffeneau.

One hundred and fifty years after the original description of spirometry by Hutchinson and 50 years after the definition of his famous ratio by Tiffeneau, a certain number of physiological advances have enabled a better understanding of the determinants of the forced expired manoeuvre and to mitigate some of its inconveniences. This review focuses on three of these advances. The first is the influence of an inspiratory manoeuvre which precedes a forced expiration, on the expiratory flow. This influence is probably a consequence of viscoelastic phenomena and impose some strains on standardisation in current practice. The second is the possibility of detecting in a reproducible and simple fashion, without the need for co-operation on the part of the subject, a limitation in expiratory flow by the application of a negative expiratory pressure at the opening of the airways (NEP for negative expiratory pressure). The third is the possibility to verify in a simple fashion the quality of the expiratory performance achieved by the patient and thus to detect an insufficient effort in the force of a falling expiratory flow.

Bronchial hyperresponsiveness following acute severe asthma.

OBJECTIVE: To evaluate bronchial hyperresponsiveness (BHR) early after recovery from acute severe asthma (ASA). DESIGN: Prospective study including all patients admitted to the intensive care unit (ICU) for ASA over a 12-month period. SETTING: University teaching ICU and pneumonology department. PATIENTS: 41 consecutive patients admitted to the ICU for ASA. Results were compared with those of a control group with stable asthma and no history of ASA or steroid therapy, matched for sex and age. MEASUREMENT AND RESULTS: Of the 41 patients, 40 completed respiratory function tests 10 days after ICU admission, and the minimal dose of acetylcholine inducing a fall in forced expiratory volume in 1 s (FEV1) of 20% or more (PD AC) could be determined safely by a novel method in 26 patients with an FEV1 above 60% predicted. PD AC (micrograms) was found to be significantly lower in ASA than in control patients. Very severe BHR (PD AC < or = 100 micrograms) was found in 18 ASA patients, but not in the control patients; 5 ASA versus 12 control patients had marked BHR (100 > PD AC < or = 500 micrograms); and 3 ASA versus 14 control patients had moderate BHR (> 500 micrograms). A similar level of BHR was found in ASA patients with progressive or acute worsening. No correlation was found between PD AC and admission PaCO2 value, admission peak expiratory flow (PEF) value, delay in improvement of PEF, delay in PD AC determination, or prechallenge FEV1 value. CONCLUSION: BHR measurement is safe soon after an episode of ASA if done with caution. At this time, patients who are free of clinical symptoms and have no significant objective bronchial obstruction appear to have severe bronchial hyper-responsiveness.

Extracorporeal photochemotherapy treatment for acute lung rejection episode.

BACKGROUND AND METHODS: We investigated extracorporeal photochemotherapy--which consists of the collection of blood mononuclear cells by means of a cell separator, their exposure to ultraviolet A light in the presence of a photoactivatable molecule such as 8-methoxypsoralen, and their intravenous reinjection into the patient--for the treatment of an acute lung rejection episode in a severely infected patient, assuming that its mechanism of action is an immunomodulation rather than an actual immunosuppression. RESULTS: Three weeks after the simultaneous beginning of antiinfectious and extracorporeal photochemotherapy treatments, the patient improved clinically. Acute lung rejection was no longer detectable histologically 4 weeks after the beginning of extracorporeal photochemotherapy. Twenty-two months after the beginning of extracorporeal photochemotherapy (47 months after transplantation), the patient was living a normal life. CONCLUSIONS: We believe this treatment may be considered for further studies not only in acute lung rejection therapy when intensive immunosuppression is contraindicated but also as a means of rejection prevention.

Longitudinal observations of serum IgE and skin prick test response.

The objective of the study was to assess skin prick test and IgE changes in a working population surveyed 5 yr apart and to determine whether age and smoking habits modify these changes. SPTs were performed on 223 subjects by the same method and common allergens (a mixture of grass pollens and a mixture of 95% house dust and 5% house dust mite). IgE measurements were done in duplicate by the same technique at each survey. A SPT-positive response at the first survey was highly predictive of a positive value at the second survey. The prevalence of positive SPT significantly increased in 5 yr (from 17.5 to 24.7%). A strong correlation was observed between IgE levels 5 yr apart (r = 0.92), and the IgE level appeared very stable. The initial IgE level was significantly greater among the converters than in consistently negative subjects (92.3 versus 30.1 IU/ml). Conversely, the initial IgE level was lower for the reverters than in consistently positive subjects (36.8 versus 97.0 IU/ml). In SPT negatives, non- and exsmokers had a greater decrease in IgE than current smokers (p = 0.06). IgE level appears to be a good predictor of SPT changes for both conversion and reversion. The IgE level appears very stable in midadulthood, which suggests that the adult environment may play a small effect in IgE level.

Nutritional status of patients with chronic obstructive pulmonary disease and acute respiratory failure.

The prevalence and features of malnutrition in COPD patients have been studied extensively in stable conditions but are poorly defined in the presence of acute respiratory failure (ARF). Nutritional status was prospectively assessed, on hospital admission, in 50 consecutive COPD patients presenting with ARF, 27 of them requiring mechanical ventilation (MV). Malnutrition, defined on a multiparameter nutritional index, was observed in 60 percent (30/50) of all patients, and in 39 percent (13/33) of those whose body weight was equal to or above 90 percent ideal body weight (IBW). Malnutrition was more frequent in those patients who required MV than in those who did not (74 percent vs 43 percent, p < 0.05). Subcutaneous fat stores were decreased (triceps skinfold thickness [TSF] < 80 percent pred) in 68 percent of patients, and markedly depleted (TSF < 60 percent pred) in 52 percent of them. The indices of lean body mass, ie, mid-arm muscle circumference (MAMC) and creatinine height index (CHI) were decreased in, respectively, 42 percent and 71 percent of patients, but MAMC was severely depressed (< 60 percent pred) in only 6 percent of them. A severe decrease of prealbumin (< 100 mg/L), retinol-binding-protein (< 20 mg/L), and albumin (< 20 g/L) serum concentrations was observed in, respectively, 22 percent, 28 percent, and 4 percent of patients. These results suggest that an assessment of nutritional status using a multiparameter approach should be systematically performed in COPD patients with ARF, especially in those requiring MV, as malnutrition may have deleterious effects on weaning off MV.

Occupational hypersensitivity pneumonitis in a smelter exposed to zinc fumes.

A smelter exposed to zinc fumes reported severe recurrent episodes of cough, dyspnea and fever. Bronchoalveolar lavage showed a marked increase in lymphocytes count with predominance of CD8 T-lymphocytes. Presence of zinc in alveolar macrophages was assessed by analytic transmission electron microscopy. This is the first case of recurrent bronchoalveolitis related to zinc exposure in which the clinical picture and BAL results indicate a probable hypersensitivity pneumonitis.

Relationships of haptoglobin level to FEV1, wheezing, bronchial hyper-responsiveness and allergy.

The relationships of haptoglobin level to respiratory and allergic parameters have been assessed in an epidemiological study conducted in a working population surveyed twice 5 years apart. At the first survey conducted in 892 working men, haptoglobin level was significantly related to FEV1 (r = -0.18; P less than 0.001) and smoking habits. After adjustment for smoking, a history of wheezing was significantly related to lower haptoglobin level. A second survey conducted in 304 men of the original sample 5 years later confirmed that haptoglobin was related to FEV1 (r = -0.21; P less than 0.001) and that wheezing was significantly related to hypohaptoglobinaemia (lower decile; P = 0.04). Men who exhibited bronchial hyper-responsiveness to methacholine had haptoglobin levels 0.35 g/l higher than those who did not (P = 0.01). Haptoglobin level was unrelated to IgE level and skin prick tests. These results support the hypothesis of the role of inflammation in both lower lung function and bronchial hyper-responsiveness. They suggest that some heterogeneity exists within subjects with a history of wheezing.

Relationships of total IgE level, skin prick test response, and smoking habits.

Epidemiologic observations on 331 men showed that increased serum IgE concentration was associated with a wheal response to skin prick testing, but also to an erythema response in the absence of any wheal, and to heavy smoking. The association between IgE and the various skin prick test responses remained after taking into account smoking and asthma.

Blood eosinophilia and FEV1. Cross-sectional and longitudinal analyses.

A previous cross-sectional analysis of 1980 data from a population of working men in the Paris area has shown a significant relationship of blood eosinophilia to a reduced FEV1 among nonsmokers, remaining after excluding men with a history of asthma. In the present report, we reexamine this relationship, after taking into account asthma, bronchial hyperresponsiveness, and positive skin prick tests, using data collected in 1985 in a subsample of 363 men from the initial population. Blood eosinophilia, defined by 5% or more eosinophils or by 250 or more eosinophils per cubic millimeter appeared to be associated with a lower FEV1, primarily in nonsmokers. A difference of approximately 0.40 L was observed in never-smokers with eosinophilia (greater than or equal to 5% of eosinophils) compared with those without. This association persisted after exclusion of subjects with atopy, asthma, and bronchial hyperresponsiveness. Longitudinally, no significant association was observed between 1980 eosinophilia and the annual FEV1 decline between 1980 and 1985, even in nonsmokers. The results of our cross-sectional analyses suggest that asthma or asthma-like disorder does not explain the association between eosinophilia and FEV1. The role of eosinophil in respiratory disorders may go beyond its intervention in allergy. Further longitudinal studies are needed to better understand discrepancies between cross-sectional and longitudinal data and whether eosinophilia is a risk factor for chronic air-flow limitation.

[Respiratory function abnormalities and pneumonia in HIV-positive patients. A prospective study of 112 patients]. / Anomalies fonctionnelles respiratoires et pneumopathies des patients VIH+. Etude prospective de 112 patients.

Pulmonary function studies are often limited to the alone measurement of transfer lung factor for CO (TLCO) in screening for pneumonia in patients with Human Immunodeficiency Virus (HIV) infection. We prospectively measured pulmonary function tests (PFT) in 112 HIV seropositive patients. The population consisted of two groups: on one hand, a group free of clinical and radiological abnormalities, on the other hand, one with respiratory symptoms and/or abnormal chest X-Ray, with or without overt pneumonitis. For this latter group, a fiberoptic bronchoscopy with bronchoalveolar lavage was routinely performed in addition to PFT. In case of pneumonitis, PFT showed a restrictive disease and a reduced TLCO. The specificity of this functional pattern was however weaker in the subgroup of drug abusers than in the non-drug addicts. This difference was above all linked to a low TLCO value in the subgroup of drug addicts without pulmonary complications. Multivariate statistical analysis, including discriminant analysis, maintained the same sensibility and improved specificity of PFT in diagnosis of pneumonia, especially if the analysis takes the existence of drug abuse into account. Moreover, initial PFT, performed before any lung disease, improved the sensibility of the screening. The results are discussed in relation to new tests proposed for the screening of pneumonitis in HIV positive patients. At the present time, PFT seems to be useful and enables one to understand natural functional evolution.

Fructose is as good a fuel as glucose for exercise in normal subjects.

50 g fructose and 50 g glucose loads, naturally 13C labelled, were orally administered in random order to six healthy subjects submitted to 90 mn exercise at VO2 max/2 on a treadmill. 13CO2/12CO2 variations in the expired air were followed before and after exercise for a total of 240 min. On the whole, fructose appeared to be as good a fuel as glucose during exercise even if slight but significant differences in kinetics were observed: the delta 13C peak values at 90 min were significantly lower with fructose. Between 90 and 240 min, delta 13C remained higher but not significantly with 13C-fructose than with 13C-glucose. During exercise, plasma glucose and insulin levels were significantly lower (p less than 0.05 and p less than 0.01) after fructose than after glucose. We conclude that fructose can be readily used during exercise by healthy subjects.

[Effect of a single dose of nifedipine on the CO transfer capacity in patients with scleroderma]. / Effet d'une prise unique de nifédipine sur la capacité de transfert du CO de patients sclérodermiques.

The calcium antagonists are currently used in the treatment of Raynaud's syndrome for patients with scleroderma. The effect on the pulmonary vasculature in these patients is little understood. The study reported here is based on 15 patients with scleroderma. In each patient lung volumes, expiratory flow and transfer factor (DLCO) were carried out in a basal state and one hour after the administration of sub lingual nifedipine. Nine patients showed a diminution in the DLCO before taking the product but the mean variation after nifedipine was not significant. Different mechanisms may explain the absence of any effect: irreversible vascular disease or the absence of pulmonary arterial hypertension or hypoxic constriction, the latter conditions were previously associated with the efficacy of nifedipine. Thus it does not seem that nifedipine, in acute tests, has an effect on the pulmonary localisation of scleroderma, at least in the absence of pulmonary arterial hypertension.

[Pneumocystis carinii pneumonia in AIDS patients. Aspects of clinical evolution in 37 cases]. / Pneumopathies à Pneumocystis carinii au cours du SIDA. Aspects cliniques et évolutifs. A propos de 37 cas.

This study concerns 37 cases of Pneumocystis carinii pneumonia in AIDS patients. The time elapsed between human immunodeficiency virus (HIV) seropositivity and the onset of pneumocystosis has been established. Three clinical types are individualized. In cases with normal X-ray films of the chest, measurement of carbon dioxide transfer capacity, always reduced, has led to a bronchoalveolar lavage which provided an early diagnosis. In spite of good response to treatment, the prognosis of pneumocystosis is poor owing to the frequency of associated diseases.

Relation of perceived nasal and bronchial hyperresponsiveness to FEV1, basophil counts, and methacholine response.

Perceived nasal and bronchial hyperresponsiveness to tobacco smoke and cold air were assessed in 912 working men in the Paris area. Baseline lung function measurements and peripheral leucocyte counts with standard differential counts were performed. At least one perceived nasal or bronchial hyperresponsiveness symptom was reported by 15.7%. Current smoking was significantly less frequent among those with cough induced by tobacco smoke. Rhinitis induced by cold air was associated with lower FEV1 (p less than 0.01) and the association remained after adjustment for smoking, asthma, and wheezing (p = 0.06). Symptoms induced by cold air were related to circulating basophils. Neither perceived nasal nor perceived bronchial hyperresponsiveness was significantly related to the airway response to methacholine in a sample of the group (n = 324) surveyed again five years later. The result suggest that the symptom of rhinitis provoked by cold air is a possible "new" risk factor or marker for chronic airflow limitation.